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耐药性癫痫的评估和治疗

Author
Joseph I Sirven, MD
Section Editor
Timothy A Pedley, MD
Deputy Editor
April F Eichler, MD, MPH
Translators
汪凯, 主任医师，教授

引言

抗癫痫药物(antiepileptic drug, AED)不能成功缓解癫痫发作的癫痫患者被认为具有耐药性癫痫(drug-resistant epilepsy, DRE)。这种情况也被称为顽固性、药物难治性或药物抵抗性癫痫。多达20%-40%的癫痫患者(约400,000美国人)可能有难治性癫痫。美国癫痫患者的每年医疗费用估计约为125亿美元(根据一项1995年的调查)，其中DRE的治疗费用占很大一部分[1,2]。DRE患者的癫痫相关残障负担最大，这进一步延伸了相关问题的范畴。

由于个体化治疗的需要，没有严格的指南能适用于确定医学难治性，然而，基于人群的研究提供了关于DRE预后的信息，有助于制定治疗方案。对于许多部分性DRE患者，手术切除有可能会消除癫痫发作。

本专题将讨论DRE患者的评估和治疗方法。其他有关癫痫发作及癫痫患者评估和治疗的内容参见其他专题。 (参见“成人癫痫处理概述”和“成人首次癫痫发作的评估”和“成人癫痫的初始治疗”和“成人癫痫的手术治疗”和“迷走神经刺激疗法治疗癫痫”)

定义

传统意义上，3种AED治疗无效即认为是难治性癫痫[3-11]。随着近年来有了许多新型AED，可能已有人预期在确定为难治性癫痫之前，会推荐患者尝试更多的药物，而不是较少的几种。然而，数项前瞻性病例系列研究已表明，2次治疗尝试失败后就很有可能是难治性癫痫，因为随着每一次AED治疗的失败，其他药物成功治疗的可能性也会降低[5-13]。例如，一项研究对1098例确诊为癫痫的青少年和成人患者开始了初次AED治疗，并进行了最长达25年的随访(中位时间7.5年)。首次药物尝试时，49%的患者达到无癫痫发作。第2次药物尝试后另有13%的患者得到缓解，但是在第3次药物尝试后仅有额外4%的患者无癫痫发作[13]。在此队列中，这些AED反应模式大多会随时间推移而持续存在。

一个国际抗癫痫联盟工作组提出，DRE被定义为经2次能耐受的、恰当选择和给药的AED(无论单用或联用)充分尝试后无法消除癫痫发作[12]。他们也推荐用DRE代替“顽固性癫痫(intractable epilepsy)”这一术语。

                      

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Literature review current through: 2017-07 . | This topic last updated: 2017-05-30.
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